Stress and Dissociative Disorders

Stress and Dissociative Disorders Lecture Notes Outline

I. Background

  • Presenting stress and dissociative disorders together is a recent development but is logical due to their interconnected nature.

  • Stress and trauma encompass both psychological and physiological reactions to stressors or traumatic events.

  • Psychological Reactions:

    • Emotional responses (e.g., anxiety, fear)

    • Cognitive reactions (e.g., thoughts related to the trauma)

  • Physiological Reactions:

    • Activity in the hypothalamus

    • Autonomic nervous system (ANS) arousal

    • Involvement of endocrine glands, notably the pituitary and adrenal glands, which produce hormones like cortisol and adrenaline.

II. Stress Disorders: "Abnormal" Reactions to Traumatic Events

A. Posttraumatic Stress Disorder (PTSD)

  • DSM Criteria:

    1. Direct or indirect exposure to trauma involving death, serious injury, or sexual violence.

    2. Presence of intrusion symptoms (e.g., flashbacks, nightmares).

    3. Persistent avoidance of reminders associated with the trauma.

    4. Negative alterations in cognition and mood related to the event.

    5. Heightened arousal and reactivity (e.g., hypervigilance).

    6. Functional impairment or distress lasting over one month.

  • Lifetime Prevalence: Over 6%.

  • Possible Traumatic Events:

    • Singular events or chronic exposure can cause PTSD.

    • Combat, disasters (natural/man-made), accidents, victimization (sexual assault, mass shootings), and torture are significant contributors.

    • Human-related events are more likely to induce PTSD.

    • Large-scale events have a higher incidence of PTSD outcomes.

  • Etiology:

    • Biological Factors: Inherited predispositions affecting stress circuits (prefrontal cortex, hippocampus, amygdala).

    • Early Experiences: Factors like chronic stress, poverty, and abuse can increase risk.

    • Cognitive Factors: Poor memory, intolerance of uncertainty, lack of coping skills, and resilience issues.

    • Social Factors: Absence of adequate social support systems.

  • Treatment Options:

    • Medications: antidepressants and anti-anxiety medications.

    • Therapeutic approaches: support groups, insight-oriented therapies (cognitive, psychodynamic, existential), prolonged imaginal exposure, and EMDR.

B. Acute Stress Disorder

  • Similar to PTSD but symptoms last less than one month.

C. Adjustment Disorders

  • DSM Criteria:

    • Milder reactions to stressors that are still clinically significant.

    • Symptoms can include anxiety, depression, or behavioral changes.

    • Fairly common but not always formally diagnosed.

III. Dissociative Disorders: Disturbances in Consciousness in Response to Trauma

A. Dissociative Amnesia (and Fugue)

  • DSM Criteria:

  • Types of Memory Loss:

    • Localized: loss of memory for events within a specific period (most common).

    • Selective: sporadic memory loss ("spot erasures").

    • Generalized: loss of memory for personal history.

    • Continuous: often organic in basis.

  • Fugue:

    • Previously a separate diagnosis but now a subtype of dissociative amnesia.

    • Characterized by unexpected travel with amnesia for one's identity.

    • Duration can range from hours to years and is often triggered by stressors.

    • Must rule out other causes like substance-related blackout, seizures, or feigning.

B. Dissociative Identity Disorder (DID)

  • DSM Criteria:

    • Characterized by two or more distinct identities or personality states, each with its own patterns of perceiving, relating to, and thinking about the self and the environment.

  • Controversial diagnosis; some believe it may not exist and is potentially iatrogenic.

  • Forms include mutually amnesic, mutually cognizant, and partially amnesic identities (most common).

C. Depersonalization/Derealization Disorder

  • DSM Criteria:

  • Characterized by recurrent experiences of depersonalization (feeling detached from oneself) or derealization (feeling detached from reality).

  • Symptoms can accompany anxiety or panic attacks, with individuals remaining in touch with reality.

  • Experiences are illusions and not hallucinations.

D. Etiology and Treatment for Dissociative Disorders

  • Primarily psychodynamic approaches for treatment.

  • Dissociative symptoms tend to be directly linked to highly stressful events.

  • DID often emerges from chronic childhood abuse leading to the formation of multiple identities as coping mechanisms.

  • Dissociative amnesia may remit spontaneously but therapy can support recovery and stress management.

  • Treatment Strategies:

    • Long-term psychodynamic therapy, focusing on identity reintegration.

    • Challenges include emergence of new identities and resistance to reintegration, often requiring a mourning process in treatment.